There are times when a doctor knows he’s doing the wrong thing and does it anyway. I’ve done it quite often. This happens when I order laboratory tests for no good medical reason. I am ordering them just to help my patient get their operation or procedure.
A 68 year old man comes to see me for cataract surgery. He has some diabetes which is well controlled with oral medications, and some mild hypertension.
The ophthalmologist’s office sends a piece of paper with him. He needs an EKG, a metabolic panel, and anticoagulation studies. None of this, of course, has anything to do with his cataract surgery. Indeed, if you look up the recommendations of the ophthalmologists regarding cataract removal, they say no labs are needed in a comparatively healthy man.
I grumble, grind my teeth, and then…I order the labs. If I am feeling particularly frustrated, I explain to the patient that I am ordering these labs just to make sure the procedure happens as scheduled, but I don’t think they are medically indicated. I am not sure the patient ever understands what I am talking about when I give this little speech.
What is wrong with these labs, anyway? First, of course, it’s the principle of sticking a needle in someone’s arm and taking blood for a test which is not of any use. Second is that labs can lead to harm. A false positive can lead to more testing, labeling, anxiety, and significant morbidity from the vicious cycle of diagnosis-treatment-side effect which we are so often mired in.
If that’s the case, how do we change matters? That’s something I don’t think anyone’s figured out yet. I played a small part, through the National Physician Alliance’s Top 5 lists of most commonly done useless and potentially harmful procedures, in the birth of the Choosing Wisely movement, which has since been publicized by the American College of Physicians and the American Board of Internal Medicine Foundation. But limiting preoperative labs is actually not part of this campaign.
This is such a difficult problem to fix because it involves everyone at once. The specialist requests these tests because that’s the way it’s always been done, perhaps just because they still have 750 copies of the pre-op handout. The receptionist in their office wouldn’t understand if an internist raised a fuss; she might likely think that the doctor was just being a jerk, and then the patient (caught in the middle, as usual) would not get their cataract removed as scheduled. Then everyone would be annoyed at the doctor who got in the way.
As usual, it’s easier to go along and get along, even at the price of unnecessarily disruptive and unneeded procedures. Can we all sit down together and try to wean ourselves of the needless INRs?
This is a very cogent explanation that will help lots of docs and “consumers” understand why too many tests are done. Two additional points:
1. How many patients are injured or killed in accidents resulting from trying to get to visits for blood testing?
2. Virani, et al, have shown (recently) that we simply do more tests than we need or use.
http://archinte.jamanetwork.com/article.aspx?articleid=1705724
Well done!
Thank you. Number 1 is an interesting point that I haven’t seen mentioned elsewhere. You can expand the concern by asking – how often are patients asked to come in for visits which aren’t necessary? Regarding the reference in 2, I definitely agree and would commend the Choosing Wisely campaign to you (linked above) if you don’t know it already.
Again, am I doing too much “do as I say, not do as I do”? For the record, I’m not a physician, but I simulate them in clinical decision support software and have been doing so in clinical decision support software,
I have a generally very good endocrinologist with a horrible staff — it’s getting better now that I send faxes. In our last meeting, he wondered why I wasn’t taking metformin.
“I’d absolutely love to…if I could. Lost 30 pounds in a month and had the best glucose control in my life. Unfortunately, my BUN and creatinine went up rapidly, and we concluded it just wasn’t safe for me. No lactic acidosis, though,the deadly complication.”
“How about trying again? That was 12 years ago, and you are on other drugs that might manage that complication. I’ve seen it give a transient elevation of kidney functions, but then stabilize.”
“Fine with me, as long as we monitor. How about a BMP weekly? (chemistry panel that covers the kidneys and a few other relevant things.”
“Oh, a month should be good enough.”
“Doctor, when I reacted before, there were significant changes weekly.”
Eventually the PCP ordered the more intensive testing.
Metformin does not increase BUN or creatinine. It is the other way. If BUN or creatinine increases for some reason (severe diarrhea, infection, dehydration, allergic reaction or overdose to toxic medicine to the kidneys) you might get lactic acidosis due to metformin (although the certainty of that association is close to zero). Thus the BMP testing and your worry are not warranted because you seem to have gotten the cause-effect arrow inverted.
Agree with kerunit: We do a poor job of explaining concepts like this as docs. I have had so many people tell me “I can’t take metformin because it damaged my kidneys”. No, people who HAVE kidney impairment should be cautious….metformin is cleared from the body through the kidneys so if a person has kidney impairment, they should take a lower dose of metformin. I also agree with kerunit that the likelihood that metformin causes lactic acidosis is almost certainly zero. One final thought: why get “BMP”? (which is 7 or 8 tests). Why not just get a creatinine?